Spanish Community Health Worker II - Community Health Program

MGH strives to advance health equity, improve health outcomes, and promote well-being of our primary care patients by addressing health-related social needs, system navigation, and care coordination as standard of care. This position will contribute to these efforts through collaboration with the Department of Equity and Community Health (ECH) and the Department of General Internal Medicine (DGIM) Population Health Management teams.

ECH oversees a team of Community Health Workers (CHWs), trusted members of the community with skills to understand patients' circumstances. CHWs build trusting relationships, address medical and psychosocial needs, promote self-efficacy, help patients meet goals, and improve health outcomes. The DGIM Population Health Management team develops and implements population-based efforts to monitor and improve clinical effectiveness through systems-based strategies and interventions, aiming to enhance the quality and cost-effectiveness of healthcare.

The Community Health Worker (CHW) will be part of the pediatric CHAMPION Program's multidisciplinary care team, including a physician and dietitian. The program evaluates whether telehealth versus in-person delivery is equally effective in reducing child BMI and asthma control in lower-income families. It involves individual and group visits, follow-up calls, educational materials, social determinants of health screening, referral, and text messaging to support behavioural change.

The CHW will provide case management for children and adolescents with overweight/obesity and asthma, via in-person and virtual visits. Responsibilities include supporting patient follow-up, goal setting, motivation, connecting to community organizations, and participating in quality improvement activities. The role involves clinical scheduling, reminder calls, telehealth technical support, and visit management tasks.

Under ECH and DGIM management, the asthma-lifestyle CHW will support primary care physicians and practices in managing patients with asthma and/or obesity, incorporating clinical and family goals, organizing patient data, identifying unmet needs, engaging in self-management, and providing wrap-around support outside traditional clinical care. The CHW will engage patients and families, develop trusting relationships, assist with navigating the health system, make home visits to identify environmental factors, and communicate with the clinical team based on clinical goals. They will also help set and track short-term goals, address barriers to care, and provide coaching to promote engagement and achievement of care goals. This is not a clinical position but requires knowledge of basic clinical concepts and understanding of referral processes to licensed clinicians.

Key Areas of Responsibility:

• Team member of the ECH and DGIM population health management program, providing health coaching and care coordination.

Principle Duties and Responsibilities:

• Patient Engagement and Health Coaching

• Engage patients via phone, home visits, and in the PCP office, including occasional accompaniment to appointments and community services.
• Facilitate weekly group sessions with families (virtually/in-person), managing reminders, planning, and conducting visits.
• Meet monthly with the multidisciplinary team focusing on goal setting, physical activity, and community connections.
• Identify and address barriers to care, conduct home visits, and help families manage appointments, prescriptions, and environmental factors.
• Provide culturally sensitive services, utilizing interpretation as needed.
• Participate in learning communities and quality improvement activities.
• Connect families with community resources to promote healthy lifestyles.
• Communicate with families via phone to support clinic attendance and goals.
• Perform other duties as required.

• Systems Navigation and Care Coordination

• Assist with logistical barriers, scheduling, childcare, and telehealth access.
• Help organize medical records, follow-up appointments, and medication management.
• Reinforce care plans and health education with primary care providers.
• Advocate and support access to community and hospital programs.
• Refer issues to case management services when necessary.

• Collaboration and Documentation

• Use patient registries to monitor high-risk patients and document encounters thoroughly.
• Maintain communication with healthcare providers and support team development of patient-centered care goals.

Additional Responsibilities:

• Attend training and continuing education sessions.
• Conduct initial assessments to identify focus areas with high-risk patients.

Qualifications include a high school diploma or GED, relevant community or academic experience, and proficiency in English. Experience in paediatric weight management, motivational interviewing, or related fields is preferred. The position is grant-funded. Skills required include problem-solving, persuasion, cultural competence, time management, and proficiency in Microsoft Office. Fluency in Spanish or other languages is desirable. The General Hospital Corporation is an Equal Opportunity Employer, committed to diversity and inclusion, providing reasonable accommodations as needed.